Prices for CBAM branches in Canada:

Note: Prices may vary in other countries

$80 PRP | $80 Mesotherapy

(Plus applicable local taxes)

Contact Information

Name*

First Last

Phone*

Email*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Treatment Information

The treatment you are interested in:*

*(you may select more than one)

Select All
PRP
Mesotherapy

Which area(s) would you like the PRP procedure?

Only applies to those seeking PRP treatment.

Select All
Face
Hair

Which area(s) would you like the Mesotherapy procedure?

Only applies to those seeking Mesotherapy treatment.

Select All
Acne Scars
Face Shine

Have you had any treatments (PRP/Mesotherapy) before?*

Yes
No

How long ago was your last treatment?

Were there any previous complications from the treatment?*

Yes
No

Please describe what was the complications:

Are you looking to correct a previous treatment?*

Yes
No

Please describe what are you exactly trying to correct from previous treatments done by other practitioners:

Do you have any allergies?*

Yes
No

Please explain about your allergy:

Do you have any of the following?*

Yes
No

• Cancer • Anemia • History of actinic keratosis • Diabetes • Autoimmune disease (scleroderma) • Recent fever or illness • Keloid scars • Active infection in treatment area

Which one?

Do you have any of the following?*

Yes
No

• Heavy smoking • Alcohol overuse • Currently on antiplatelet therapy • Currently pregnant or breastfeeding

Which one?

Select an Appointment Time

Please select a time for your appointment:

August 29th, 2019 - Toronto, Ontario - 12:30 to 3:30 pm
September 27th, 2019 - Toronto, Ontario - 12:30 to 3:30 pm

You may select multiple dates for your treatment. Someone from our models team will call you or text you to arrange with you the exact time of the appointment.

How did you hear about us?*

Facebook
Google Ad
Instagram
Friend/family referral
Expo
Special event
Other

Please explain:

STUDENT REFERRALS: Who referred you?

Comments

Consent*

I have read and agree to the cosmetic model terms and conditions

PRP, Mesotherapy and Microneedling Model Application